Holding Birth Control Hostage

7:30 pm - 04/30/2012

Doctors still require women to submit to cancer screenings and pelvic exams to get birth control pills. Scientists say that shouldn't happen.

Recently, my doctor gave me an ultimatum: Come in for a pelvic exam, or I won't refill your birth control pills. The problem arose after I tried to get my prescription refilled before going on vacation in March, only to be told that the doctor's office wouldn't sign off on the refill because it had been a year and one month since I'd had an annual exam and a Pap smear. A nurse grudgingly gave me a monthlong reprieve if I promised to come in for an exam when I returned from my trip.

I really, really didn't want to go in for an exam. I've had two kids, a false positive Pap test and all the ensuing misery that comes with it, and spent enough time in the stirrups to last a lifetime. All I really wanted were my pills; I was pretty sure the exam could wait another year or more.

The science was on my side.

Just a few weeks earlier, the US Preventative Services Task Force, an independent group of national experts that makes evidence-based health care recommendations, released new guidelines declaring definitively that women over 30 don't need a Pap smear more than once every three years unless they have a couple of risk factors, which I don't have. The American Congress of Obstetricians and Gynecologists has said that birth control pills can safely be prescribed without a full-on exam.

Doctors, though, don't seem to be in any hurry to give up old habits. After I got back from vacation, I emailed my doctor, citing the new guidelines, and asked if he could give me a new one-year prescription for birth control pills without a pelvic exam. He wrote back, "Yes, one can argue about whether or not you need a pap, but current recommendations are still for an annual exam, blood pressure readings, updating family history, ('torturous pelvic exam,' I'm afraid), etc. So I would still like you to come in. See you soon?"

The doctor had me over a barrel. As it turns out, my experience isn't unique. Doctors regularly hold women’s birth control prescriptions hostage like this, forcing them to come in for exams that research is increasingly showing are too frequent and often unnecessary and ineffective. A 2010 study published in the journal Obstetrics & Gynecology found that 33 percent of doctors always require a pelvic exam and Pap smear for a hormonal contraception prescription, and 44 percent regularly do so, even though there's no medical reason for linking the two.

Indeed, there's a growing body of evidence that the entire annual ob-gyn exam, with the mandatory and miserable pelvic exam where doctors poke around one's uterus and ovaries with their fingers, is largely obsolete. For instance, there's no evidence that doctors can diagnose ovarian cancer with a pelvic exam in women showing no symptoms. A clinical trial found that doctors were unable to identify any cancers in test subjects by pelvic exams alone, and the National Cancer Institute no longer recommends the tests for postmenopausal women. Even chlamydia screenings, which are recommended for women under 26 and those at higher risk for the sexually transmitted disease, can be done by simply having women pee in a cup, and don't require an invasive and expensive exam.

The scientific basis for much of the traditional well-woman ob-gyn annual check-up is so slim that "the routine pelvic examination may be an example of more service leading to worse outcomes," Dr. Carolyn Westhoff, an ob-gyn at Columbia University, wrote in the Journal of Women's Health last year.

Indeed, all this excess treatment has serious negative effects. Mandatory pelvic exams often deter women from seeking contraception in the first place. Failing to get contraception puts women at risk for the much more likely problem of an unwanted pregnancy, which is far more dangerous than getting birth control pills without a pelvic exam.

Despite not being very good at detecting cancer, annual pelvic exams are great at turning up stuff that if left alone would never cause a problem—things like noncancerous fibroids and ovarian cysts the patient never noticed. Discovery of such "problems" in exams usually leads to a surgical intervention. "The clinical trial data show no evidence that pelvic examination improves the early detection of ovarian cancer or diagnosis of other conditions in women who have no symptoms," Westhoff says. "Overuse of the pelvic examination contributes to high healthcare costs without any compensatory health benefit."

Westhoff and her colleagues suggest that the mandatory annual pelvic exam is one reason American women have twice the rate of hysterectomies as their European counterparts. And the Pap smear, of course, has its own issues with false positives, which can be as high as 10 percent. One of the treatments often recommended after a positive result can double the risk of a premature delivery for women who go on to get pregnant.

Getting a false positive is no walk in the park, either. About a year and a half after the birth of my second child, I had an IUD put in for contraception, which isn't a fun procedure and is also very expensive because much of it isn't covered by insurance. A few months later, I had to go in for the requisite annual exam. My Pap test came back with problems. So I had undergo a really painful and ultimately negative endometrial biopsy, which couldn't be done without taking out the IUD I'd just had put in. Not only was I out hundreds of dollars, I also spent a week or two stressing out that I might be headed for chemo, hair loss, and dying before my children get to high school. The psychic trauma from unnecessary tests is real.

"It's harder to get doctors to quit doing certain things" than to embrace new procedures, says Shannon Brownlee, a health policy expert at the New America Foundation who wrote a book about overtreatment in America. Part of the problem, she says, is that the primary way doctors learn about new science is through continuing medical education, which they have to do to keep up their medical licenses. Most continuing medical education is funded by drug and medical device companies.

"'Don't do it' is not a message that the drug industry and the medical device industry is all that excited about," Brownlee says. Guidelines from the government trickle down very slowly to doctor's practices. And patients raise these issues at their peril, Brownlee notes. "When you have that conversation with your doctor, you often get labeled as a noncompliant patient." The health care system is also plagued with irrational incentives that reward doctors for doing more rather than less, even when it's in the patient's best interest to be judicious. Doctors need to keep their waiting rooms full to keep their practices open.

There is one way to change the system: Make the Pill an over-the-counter (OTC) drug. If women could get birth control pills from a pharmacy, like they do in other countries, and could decide for themselves whether they should have a pelvic exam every year, the country could experience serious health care savings. Unnecessary health care treatment overall is estimated to cost at least $158 billion a year.

The FDA has been considering making the Pill available without a prescription at least since 1993. But with the recent debates about health care reform and the contraceptive mandate in the new health care law, the issue has come to the forefront again with new urgency. The Pill is one of the safest regularly used drugs on the market. Not surprisingly, though, the American Congress of Obstetricians and Gynecologists hasn't signed on to the campaign, no doubt because of the prevailing view in the profession that if women could get their pills without a prescription, they wouldn't come in for annual checkups.

Prominent ob-gyns Michael Cackovic and Michael Paidas, writing in the journal Modern Medicine, reflected this view in a 2008 op-ed against the OTC pill, writing, "women who [get] OTC pills could have little motivation for annual exams, sexually transmitted infection screening or Pap smears, which could possibly manifest as less screening for cervical cancer."

Theirs is a common and paternalistic view of women patients. After all, men are never required to, say, have a colonoscopy as a condition of getting blood pressure medication, Viagra, or even a vasectomy, even though men are much worse about going to the doctor and getting checkups than women are.

Women don't need to have their birth control pills held hostage to get needed cancer screenings. That's not just my opinion. There's hard data to prove it. In many places in the world, the pill is already available over the counter, so some smart researchers have taken a look at the behavior of women who get it that way.

Dr. Daniel Grossman, an ob-gyn and senior associate at Ibis Reproductive Health, coordinates a working group pushing to make the Pill available without a prescription. With colleagues at the University of Texas, Grossman has studied women in Texas who are able to get the Pill from pharmacies in Mexico without a prescription. As it turns out, the women who make the trip, he says, "had very high rates of getting all the preventive screening tests, higher than the national average." Not only that, but women who got their pills without the hassle of an exam were much more likely to stay on the Pill continuously, a factor that research shows is directly related to fewer abortions and unplanned pregnancies.

Still, the Pill wasn't going to be available over the counter soon enough to solve my problem. Fortunately, I discovered that there is one health care provider that's a pioneer in disconnecting birth control pills from mandatory pelvic exams: Planned Parenthood. So I went there.

Passing through the bullet-proof, bomb-proof entrance to the DC clinic was a little unnerving; while I sat in the waiting room watching The View with a bunch of young women and solo men, I got slightly paranoid about errant bullets or bombs from anti-abortion nuts. But the visit turned out to be painless. After I filled out a lot of paperwork asking about my medical history, a nurse took my blood pressure—which, unlike a pelvic exam, is actually related to the potential risks of the Pill—asked me some questions about my history, and then wrote me a prescription. And unlike my doctor, she even offered to write it so that I could get three packs at a time instead of one.

Without insurance, the visit would cost $130, which isn't cheap, but it's still likely to be much cheaper than a full-on pelvic exam and all the related lab work. (Planned Parenthood also charges on a sliding scale, so the cost can be less depending on income.) It was worth it, mainly because I got my prescription without having to take my clothes off. And in a year, I might go back for a checkup with a doctor. But if I do, it will be because I think it's the right thing to do, not because I don't have a choice.

Of course. You weren't trying to imply that not receiving unnecessary exams would lead to some condition being missed that would explode your ovaries, not at all. That's not scaremongering, nope.

While it's good that your medical condition was caught, it's important to recognize that a) early detection can be harmful, as sometimes the body resolves issues on its own; and b) excessive monitoring leads to excessive treatment. Early detection may have helped you, but it's *hurt* other people, and I don't think it's fair to dismiss their injury.

i don't mean to speak for the op, but i read the last gif as tongue-in-cheek; ovaries exploding is an internet meme for the attraction that comes from seeing a really hot person or a really adorable baby human/animal.

Okay, so it's a meme. But it's echoing language that's been used to control women's medical choices for eons, that without control our reproductive bits will act up or destroy themselves, so it's a little hard to read it without seeing a "can't you take a joke?" subtext. :/

i don't know about that. i respect your interpretation, but within this specific milieu -- an ontd spinoff on livejournal, a platform that's used by a good number of people involved in fandom -- i don't think it's irresponsible of her to post it and assume people would understand what she meant without the implications you've drawn up.

i'm not calling you out for not being able to take a joke -- i'm just giving you the lay of the land.

Actually, I wasn't. That's a common gif used for fangirling. I said to keep your ovaries 'HEALTHY so they can KEEP ON "ovary explosion"ing.'

I'm not even talking about HPV/paps with my experience, although I am also experiencing that. Finding it early hasn't done anything yet for me, since we're still in the watch & wait phase to see if it handles itself. There are other vaginal health issues, such as PID caused by infections. I can't imagine how early detection would hurt anyone there.

I also want to say, I know we started off on the wrong foot up thread so let me clarify-- I know exams can be traumatizing for some and they are uncomfortable for pretty much everyone. I'm not being dismissive of you or anyone elses negative experiences with these exams, but the pelvic exams do have a purpose beyond detecting cancer. That doesn't make them not traumatizing, but gyno visits being shitty doesn't make them pointless.

The point of my post was just to encourage people to get checkups in this seemingly wall of posts of 'i hate gynos, all these visits are unnecessary' because I had the same feeling but begrudgingly went to my appointments because my mother always insisted. I didn't even suggest how often, I just want people to go. Sometimes even when you feel just fine, things aren't fine.

Apparently bullying is okay if you even whisper the mention of an atheist actually doing something /bad/. Atheists can do no wrong. Even though it was a small portion of my post, and I went on to mention several different instances of bullying, she said that, and then when called out, actually copped an attitude.

Hmn, yeah. I find this incredibly hypocritical because she places so much value on her own experiences (as seen in this post & in yours) and is adamant about people valuing her experiences & feelings, but is so swift to dismiss others'? Ughh.

I felt personally attacked and like my experience didn't matter when I saw that was the only thing she got out of my very personal post. My immediate response was but my goal wasn't to start drama so I took a breather before replying. It was just so incredibly infuriating.

I also noticed she sees fit to call encouraging people to go to the gyno to be sure there's nothing wrong fear mongering but does not see fear mongering in all the posts professing that gynos are shitty & always do unnecessary procedures, do not listen to their clients, and handle exams with no regard for the what the patient is feeling. They both instill fear/anxiety/concern about the experience or their health, but one makes people NOT want to visit doctors. Mistrust of doctors is a major reason people do not go in to get examined or treated when they present symptoms.

Also for anyone reading this, there are good gynos out there. My gyno always asks if I'm alright and if anything hurts too much. I had a transvaginal ultrasound and the nurse let me put the device in myself and was always conscious of how I was doing. She asked how I was doing and if I was uncomfortable constantly. There are also gynos who will let you hold a mirror and watch them do pelvic exams (this is a relieving factor for some) and some gynos will let you sit up during exams (this can feel like a less vulnerable position). It doesn't make the situation a happy one, but sometimes it helps if you have a really hard time with the experience. Personally, I think having a female gyno helps the chances they'll be conscientious of how you're feeling & will be more patient/understanding, but I am sure there are some conscientious male gynos as well.

I basically agree here. It's far more damaging to insist that people DON'T see a doctor, than that they do. And if they do, they can get the information from other sources on how many times every few years to see a gyn, as opposed to not going and never knowing. I would have never known that I didn't need to get that whole gyn check up but once every 2-3 years if I hadn't GONE, and she told me. I'm not saying there aren't doctors out there who will force you to come every single year, because if that wasn't the case then we wouldn't have had this article, but knowing is better than not knowing, and getting it at least DONE is better than assuming that you're better off than not knowing.

With my rampant hypochondria, I have to know, but I also got the info I needed, and this was also from a doctor at the local Planned Parenthood clinic. They also let you just pay for re-upping without the exam (thank god).

As for the poster, yeah. She's quick to judge, quick to argue, and quick to insist that she's right regardless of what you've been through, and I think that's far more hurtful than some stupid troll. For what it's worth, I think it's a thin line with gynos, and you really need to cross it first, before stepping back away from it, and evaluating what should be done. I'm extremely poor, but I am lucky to have a PP in my neighborhood, and the ability to read articles like this in order to make an informed decision on what to do when it comes to gyno season.

All of that said, I'm glad they caught whatever was going on with you! I know not everybody is so lucky, so that is a Very Good Thing™.

Often times doctors in poorer areas know that people can't afford to come in all the time, so having less frequent visits & testing seems to be pretty widely used by them already. Case & point: my doctor prescribing me meds over the phone, crunching in appointments, allowing me to get my 2 of my HPV vaccines while I had insurance, etc.

Yeah, the article doesn't apply to me (yet since I'm 23 & on 5 year bc) but I do find it to be good to know information. Though, another issue I had with the article (aside from perpetuating mistrust of doctors) is that they gave the impression that STD/STI testing is cheaper than pelvic exams. What? They charge PER test. One thing the pelvic exam does is allow the doctor to feel what is swollen/see if you have any pain with pressure, scope out your cervix, and view the discharge coming out of your cervix. Pelvic exams are done because they are cheaper than doing a full STD/STI screening and doing ultrasounds/x-rays to make sure all your parts aren't swollen or abnormal. Pelvic exams are a first line measure. They fucking suck, but they're the go-to of exams because they're cheap and check for a lot of things.

Well, lucky with the first one. I'm not sure about my HPV yet. I have to go back at the end of June too (agonizing with you) for a repeat pap, I hope my vag kicks some HPV ass or that it at least stays low-grade :(